experimental research design in nursing

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Nursing Research Priorities

Research priorities.

The ANA Enterprise Research Priorities are strategically designed to address critical challenges and opportunities in nursing and healthcare. These priorities focus on enhancing healthcare access, improving safety and quality of care, and promoting the health and well-being of nurses. They also emphasize the importance of diversity, equity, and inclusion, the development of professional identity, and environmental sustainability. Together, these research priorities aim to drive impactful changes that will shape the future of nursing and healthcare on a global scale. Download the full document to learn more about how these priorities are guiding innovative research and advancing the profession.

ANA Enterprise Research Council

The ANA Enterprise Research Advisory Council provides expert guidance and recommendations to the Institute for Nursing Research & Quality Management on matters of global importance, aimed at shaping the future of nursing and healthcare. By fostering a culture of inquiry and advancing interprofessional, practice-based research, the Council drives transformative initiatives that align with the ANA Enterprise's mission to lead the profession forward.

Composed of volunteer experts, the Council unites diverse nursing voices to steer research efforts that strengthen the global impact of nursing. It ensures that frontline nurses' perspectives are central to advancing healthcare innovations. Historically focused on building research capacity, fostering collaboration, and enhancing data governance, the Council's priorities now emphasize workforce development, nurse well-being, diversity and inclusion (DEIB), expanding the scope of practice, and demonstrating the value of nursing.

Research Advisory Council

Jen bonamer.

PhD, RN, AHN-BC, NPD-BC

Nursing Professional Development – Research Specialist Education, Professional Development & Research Department Sarasota Memorial Health Care System

Jen Bonamer works as a Nursing Professional Development – Research Specialist at Sarasota Memorial Hospital in Sarasota Florida. She leads the nursing research and evidence-based practice programs and is actively focused on supporting healthy work environments and clinician well-being. Jen received her BSN from the University of Florida (Gainesville) and practiced for ten years in pediatrics (general practice and hematology/oncology/bone marrow transplant). She completed the University of South Florida’s (Tampa) Nursing BS to PhD program with her master’s of science degree (nursing education) and PhD (nursing). She is certified in both nursing professional development and advanced holistic nursing. Jen is an active member in the American Nurses Association – Enterprise (ANAE) Research Advisory Council and an independent contractor of peer review services for the Magnet program.

Catherine H. Ivory

PhD, RN-BC, NEA-BC, FAAN

Associate Nurse Executive, Nursing Excellence Vanderbilt University Medical Center

Cathy Ivory, PhD, RN-BC, NEA-BC, FAAN, Associate Nurse Executive, oversees the Office of Nursing Excellence for the Vanderbilt Health System. Through collaboration across all VUMC and Vanderbilt University entities, The Office of Nursing Excellence is responsible for professional, evidence-based nursing practice, VUMC’s shared governance and Magnet activities, and all aspects of inquiry that translates evidence into practice and improves quality, safety, patient experience, and the delivery of cost effective care across settings. Dr. Ivory facilitates nursing research activities and connects nurse investigators with collaborators across the broader research enterprise at Vanderbilt.

Dr. Ivory has more than 25 years of experience as a staff nurse, clinical specialist, system-level nursing administrator, educator, and health services researcher. Dr. Ivory’s clinical focus is perinatal nursing and she served as the 2014 President of the Association of Women’s Health, OB and Neonatal Nurses (AWHONN), representing more than 300,000 nurses who care for women and newborns. She also holds two ANCC board certifications, one as an informatics nurse (RN-BC) and one as an advanced nurse executive (NEA-BC). She was inducted as a fellow in the American Academy of Nursing in 2017.

Dr. Ivory holds a BSN, an MSN in nursing administration/healthcare informatics, and a PhD in nursing science. Her research interests include implementation science and using data generated by nurses to quantify their role in patient care, patient safety, and patient outcomes. She is passionate about the nursing profession, nursing informatics, evidence-based nursing practice, and research.

David W. Price

MD, FAAFP, FACEHP, FSACME

Professor, Family Medicine, University of Colorado Anschutz School of Medicine Senior Advisor to the President and CEO, American Board of Family Medicine Medical Education and Quality Improvement Consultant and Coach Associate, Wentz/Miller Global Services

Dr. Price is Senior Advisor to the President, American Board of Family Medicine. He is also Professor of Family Medicine at the University of Colorado School of Medicine.

Dr. Price spent 29 years in the Kaiser Permanente (KP) system in several roles, including Director of Medical Education for the Colorado Region and the (national) Permanente Federation; physician investigator with the KP Colorado Institute of Health Research; Co-director of the Kaiser Colorado Center for Health Education, Dissemination and Implementation research; Clinical Lead for Kaiser National Mental Health Guidelines; member of the Kaiser National Guideline Directors Group, and Chair of Family Medicine for the Colorado Permanente Medical Group. He served on the ABFM Board of Directors from 2003 – 2008, where he chaired the R&D and Maintenance of Certification committees and was Board Chair from 2007-2008. He is a former Senior Vice-President at the American Board of Medical Specialties. He is a past Director of the Accreditation Council for Continuing Medical Education, a past-president of the Colorado Academy of Family Physicians, past chair of the AAMC Group on Educational Affairs section on Continuing Education and Improvement, and currently serves on the AAMC Integrating Quality Initiative steering committee. He is widely published and has spoken nationally and internationally and published in areas ranging from continuing medical education/professional development, quality and practice improvement, mental health, and evidence-based medicine.

Dr. Price received his M.D. degree from Rutgers Medical School in 1985 and completed his Family Medicine Residency and chief residency at JFK Medical Center, Edison, NJ, in 1988. He is a fellow of the American Academy of Family Physicians, the Alliance for Continuing Education in the Health Professions, and the Society of Continuing Medical Education (SACME) and the recipient of the 2018 SACME Distinguished Service in CME Award.

Marianne Weiss

Professor Emerita of Nursing Marquette University College of Nursing

Dr. Weiss is Professor Emerita of Nursing at Marquette University in Milwaukee, WI. She holds a Bachelor of Science in Nursing degree from McGill University in Montreal, Canada, and Master of Science in Nursing and Doctor of Nursing Science degrees from the University of San Diego. Prior to joining the faculty of Marquette University, she held positions as clinical nurse specialist and nurse researcher in women’s services for a large healthcare system.

Dr. Weiss continues to be an active nurse researcher and research consultant. Her program of research focuses on the contribution acute care nurses make to patient outcomes. Much of her work has focused on discharge preparation, assessment of discharge readiness, and post-discharge outcomes across the range of patients discharged from acute care hospitals. Her funded research studied the impact of nurse staffing on quality and cost measures of the discharge transition from hospital to home. Dr. Weiss was the Principal Investigator for the READI multi-site study, commissioned by ANCC and conducted at 33 Magnet hospitals, that investigated implementation of discharge readiness assessment as a standard nursing practice for hospital discharge. Other related research focuses on nurse staffing, continuity of care, and nurse characteristics such as education and certification that contribute to nurse performance in achieving patient outcomes. Her goal is to document the critical role and value hospital nurses bring to patient care and outcomes during and after hospitalization.

Instrument development has been an important aspect of her work on discharge readiness. Dr. Weiss has developed and tested research scales to measure quality of discharge teaching, discharge readiness, and post-discharge coping difficulty. She has conducted tool validation studies in adult-medical surgical patients, parents of hospitalized children, and postpartum mothers. These scales have been translated into more than 15 languages and are being used extensively in clinical practice and research. Dr. Weiss collaborates frequently with researchers worldwide on the science of discharge preparation. She has published extensively with US and international colleagues.

Olga Yakusheva

Professor of Nursing and Public Health Department of Systems, Populations and Leadership Department of Health Management and Policy University of Michigan School of Nursing and School of Public Health

Dr. Yakusheva is an economist with research interests in health economics and health services research. Yakusheva's area of expertise is econometric methods for causal inference, data architecture, and secondary analyses of big data. The primary focus of Yakusheva’s research is the study of economic value of nursing/nurses. Yakusheva pioneered the development of a new method for outcomes-based clinician value-added measurement using the electronic medical records. With this work, Yakusheva was able to measure, for the first time, the value-added contributions of individual nurses to patient outcomes. This work has won her national recognition earning her the Best of AcademyHealth Research Meeting Award in 2014 and a Nomination in 2018. Yakusheva is currently a PI on a AHRQ funded R01 measuring the continuity of interprofessional ICU care and an ANF/ANCC funded research grant measuring the value-added contribution of specialty nurse certifications to nurse performance and patient outcomes.

Yakusheva is a team scientist who has contributed methodological expertise to many interdisciplinary projects including hospital readmissions, primary care providers, obesity, pregnancy and birth, and peer effects on health behaviors and outcomes

Yakusheva holds a PhD in economics, an MS in economic policy, and a BS in applied mathematics.

Colleen K Snydeman

Executive Director, Office of Quality, Safety, Informatics, & Practice and the Inaugural MGH Endowed Scholar in Nursing Practice, Nursing & Patient Care Services, Massachusetts General Hospital

Dr. Snydeman’s expertise and leadership are dedicated to delivering safe, evidenced-based, high quality patient care through the continuous improvement of practice and positive outcomes with a focused commitment to the safety and well-being of the workforce. As the executive director of Massachusetts General Hospital’s Patient Care Services Office of Quality, Safety, Informatics, & Practice I provide oversight for quality and safety programs, improvement initiatives and outcomes associated with quality nursing care (falls, pressure injuries, central line blood stream infections, catheter associated urinary tract infections, and assaults on nursing personnel). I oversee a team of nine quality and informatics specialists and have a formal, non-direct reporting relationship with 75 unit based clinical nurse specialist and nurse practice specialists.

During the unprecedented COVID-19 era I led and supported a full implementation of Circle Up Huddles in all PCS inpatient areas, implementation of hospital-wide Proning Teams (recognized by Johnson & Johnson as a top ten innovation), pressure injury research, qualitative research on the experiences of bedside nurses and respiratory therapists, and implementation of resiliency and wellbeing strategies. In collaboration with RGI analytics, we have developed an algorithm using live streaming electronic health record data to alert nurses on their iphones to changes in patient’s fall risk and the associated interventions needed to prevent falls. Preliminary statistical findings are promising.

I have over forty years of progressive nursing leadership experience. My background in nursing leadership and critical care nursing led to my dissertation work using a quasi-experimental pre/post-test design with intervention and control groups to measure the impact of a theory based adverse event nurse peer review program on safety culture and the recovery of medical errors in the critical care setting. A linear mixed model analysis suggested that critical care nurses who participated in the program had a more critical view of safety culture and work environment, along with increased accountability and responsibility for their role in using strategies to keep patients safe. Further interdisciplinary safety research is underway.

Johana Rocio, Fajardo (Almansa)

Advanced Heart Failure & Transplant Nurse Practitioner, Duke University Hospital

As a doctor of nursing practice with a specialty in heart failure, transplant and mechanical support, my research is focused on improving patient outcomes through the development and implementation of best practices for the care of advanced heart failure patients. My clinical activities are centered on reducing healthcare inequities and improving Health Related Quality of Life (HRQoL) throughout the disease trajectory by optimizing interdisciplinary management and transitional care. Additionally, I have worked on database creation for both clinical and academic purposes as well as leveraging information technology to promote clinical practice standardization, minimize medical errors, and reduce cost of care.

Lastly, I have assisted in the establishment of centers of excellence by building the organizational, clinical, and educational infrastructures to deliver integrative, efficient, and specialized care to the Amyloidosis and Sarcoidosis populations. Furthermore, I have participated as a keynote speaker at national and international medical symposiums and have served as editor in chief and writer of textbooks. During my tenure as an Assistant Professor at Georgetown University School of Medicine, my research focused on the implementation of translational and organizational research to address specific issues in clinical practice and patient care delivery. Additionally, my work in the utilization of Inotropic support in rare cardiomyopathies was recognized as innovative in the field. By providing evidence and simple clinical approaches, this body of work has changed the standards of care for rare cardiomyopathy patients and will continue to provide assistance in relevant medical settings well into the future. I have served in the capacity of Principal Investigator, Co-Investigator, task leader, and technical consultant on projects supported by the government, industry and internal funding sources. In addition, I have successfully collaborated in randomized clinical trial conduction (e.g. patient screening, enrollment, and monitoring), and produced peer-reviewed publications.

Kathy Casey

PhD, RN, NPD-BC

Professional Development Specialist, Denver Health Adjunct Professor, University of Colorado, College of Nursing Adjunct Faculty, Colorado Christian University

Kathy Casey, PhD, RN, NPD-BC, is nationally and internationally known for her Casey-Fink Survey design work supporting graduate nurse role transition, nurse retention, and readiness for professional practice.

Kathy is certified in Nursing Professional Development, and currently serves as a Professional Development Specialist at Denver Health, in Denver, Colorado. She is an Adjunct Professor at the University of Colorado College of Nursing and Adjunct Faculty teaching EBP and Research at Colorado Christian University. Kathy is a lead appraiser for the American Nurses Credentialing Center Practice Transition Accreditation Program (PTAP).

In March 2023, Kathy received the Association for Nursing Professional Development's Marlene Kramer Lifetime Achievement Award for her contributions and research on survey development for use in education and practice programs. In October 2023, Kathy will be inducted as a fellow in the American Academy of Nursing.

Kathy received her Bachelor of Science in Nursing from Pacific Lutheran University, her Master's Degree in Nursing Administration from the University of Colorado, College of Nursing, and her Doctorate in Nursing Education from the University of Northern Colorado, School of Nursing.

Kortney James

PhD, RN, PNP-C

Dr. Kortney James is a PhD prepared nurse and Associate Health Policy Researcher at RAND Corporation. Her research focuses on improving access to quality reproductive health services to minoritized populations. Dr. James is also the Associate Editor of the Nursing for Women's Health Journal, a role in which she is committed to recruiting and supporting manuscripts and research that reflect diverse perspectives and identities. Dr. James recently completed a postdoctoral fellowship in the National Clinician Scholars Program, a continuation of the Robert Wood Johnson Foundation, in the School of Medicine at the University of California, Los Angeles. During her postdoctoral fellowship Dr. James has published several manuscripts in high impact journals. Select publications include "NIH funding: Hone efforts to tackle structural racism" featured in Nature and "Factors associated with postpartum maternal functioning in Black women," featured in Journal of Clinical Medicine. Thus far, Dr. James has been awarded $230,000 to support her research related to Black perinatal mental health. She received $30,000 from the Iris Cantor UCLA Women's Health Center to support her mixed methods study that aims to identify and understand culturally and racially relevant influences on their journey to healing from perinatal mood and anxiety disorders. Dr. James also received $200,000 from the American Nurses Foundation to implement an educational intervention to support ambulatory care nurses and other healthcare staff to care for Black pregnant and postpartum people’s mental health needs with culturally relevant resources. Dr. James has a wide range of clinical experience in acute inpatient care, primary care, and public health. Dr. James is a pediatric nurse practitioner with over a decade of experience in acute newborn care and pediatric primary care. Dr. James has extensive experience in perinatal care due to her time as a registered nurse in the highest volume birthing hospital in the country with an average of around 25,000 births a year (and counting). Dr. James has also held an executive leadership position in the Office of Nursing, Maternal Child Health, and Infectious Disease divisions at the Georgia Department of Public Health in Atlanta, GA.

Ultimately, Dr. James' mission is to co-create solutions with Black women and people capable of pregnancy to achieve health equity.

For questions or inquiries please contact the ANCC Research Council members at [email protected] .

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Trending topics in the tu online community

Nursing Research: What It Is and Why It Matters

When people think about medical research, they often think about cutting-edge surgical procedures and revolutionary new medications. As important as those advancements are, another type of research is just as vital: nursing research.

This type of research informs and improves nursing practice. In many cases, it’s focused on improving patient care. Experienced nurses who have advanced nursing degrees and training in research design typically conduct this research.

Nurse research can explore any number of topics, from symptomology to patient diet. However, no matter the focus of a research project, nurse research can improve health care in an impressive number of ways. As experts in their field, nurse researchers can pursue a wide range of unique career advancement opportunities .

Why Nursing Research Matters: Examples of Research in Action

Research drives innovation in every industry. Given that nurses are on the front line of the health care industry, the research they do can be particularly impactful for patient outcomes. 

It Can Improve Patients’ Quality of Life

Patients diagnosed with life-threatening chronic diseases often undergo intense treatments with sometimes debilitating side effects. Nursing research is vital to helping such patients maintain a high quality of life.

For example, a 2018 study led by a nurse scientist explored why cancer patients undergoing chemotherapy frequently experience severe nausea. While the physical toll of chemotherapy contributes to nausea, the study found that patients who have factors such as children to take care of, high psychological stress, and trouble performing day-to-day tasks are often much more likely to experience nausea.

By identifying the root causes of nausea and which patients are more likely to experience it, this research allows health care professionals to develop evidence-based care practices . This can include prescribing anti-nausea medications and connecting patients to mental health professionals.

It’s Central to Making Health Care More Equitabl

A Gallup survey reports that about 38% of Americans put off seeking medical treatment due to costs. Unfortunately, cost is only one factor that prevents people from seeking treatment. Many Americans don’t live close to medical providers that can meet their needs, aren’t educated about health, or encounter discrimination.

As complex as this issue is, the National Institute of Nursing Research (NINR) asserts that the country’s nurse researchers can lead the charge in tackling it. In its strategic plan for 2022 to 2026, the institute highlights the following:

• Nursing has long been one of the most trusted professions in the country.
• Nurses often interact with patients, patients’ families, and communities more frequently than other health care professionals.
• The care that nurses provide must often take environmental and social factors into account.

These traits put nurses in the position to not only research health inequity but also put their research to work in their organizations. To help make that happen, NINR often funds nurse-led research projects focused on equity and social determinants of health. With that kind of backing, the field may become more transformative than ever.

It Can Strengthen the Health Care Workforce

While nursing research can be used to improve patient care, it can also be leveraged to solve issues health care professionals face daily. Research about the state of the health care workforce during the COVID-19 pandemic is a perfect illustration.

In 2022, a team of nurse researchers published a report called Nursing Crisis: Challenges and Opportunities for Our Profession After COVID-19 in the International Journal of Nursing Practice . In it, the authors provided concrete statistics about the following:

• Mental and physical health issues many nurses encountered
• Effects of increased workloads and decreased nurse-to-patient ratios
• How many nurses were planning to leave the profession altogether

As nurses themselves, the authors also offer actionable, evidence-based solutions to these issues, such as streamlining patient documentation systems and implementing employee wellness programs.

However, this type of research isn’t just important to solving workforce issues stemming from specific emergencies, such as the COVID-19 pandemic. By publishing quantifiable data about the challenges they face, nurse researchers empower other nurses and professional nursing organizations to advocate for themselves. This can help employers enact effective policies, support their nursing staff, and draw more talented people into the profession.

Career Opportunities in Nursing Research

Nurse researchers can work in any number of administrative, direct care, and academic roles. However, because nurse research often requires clinical care and data analysis skills, jobs in this field typically require an advanced degree, such as a Master of Science in Nursing (MSN).

While many more nurse research career opportunities exist, here are four career paths nurses with research experience and advanced degrees can explore.

Nurse Researcher

Nurse researchers identify issues related to nursing practice, collect data about them, and conduct research projects designed to inform practice and policy. While they often work in academic medical centers and universities, they can work for any type of health care provider as well as health care advocacy agencies.

In addition to conducting research, these professionals typically provide direct patient care. Many also write papers for peer-reviewed journals and make presentations about their work at conferences.

Clinical Research Nurse

Despite having a similar title to nurse researchers, clinical research nurses have slightly different responsibilities. These professionals are usually in charge of providing care to patients participating in medical research projects, including clinical trials and nursing research initiatives. They also typically collect data about patient progress, coordinate care between different team members, and contribute to academic papers.

Occupational Health Nurse

Also referred to as environmental health nurses, occupational health nurses serve specific communities, such as professionals in a particular industry or people who live in a particular area. They often educate their communities about relevant health risks, advocate for stronger health and safety regulations, and run wellness programs.

To carry out their duties, occupational and environmental health nurses must typically research health trends about the people they serve, including living and working conditions that put them at risk for illness or injury. They can work for private companies and government agencies.

Nurse Educator

Nurse educators prepare new nurses to enter the workforce or train experienced nurses in more advanced techniques. This can include teaching classes and providing on-the-job training. They often work for colleges, universities, and large health care providers.

While their duties don’t always include research, nurse educators must keep up with the health care industry’s needs and new patient care practices. This is so they can provide relevant education themselves and help their organizations design up-to-date curricula.

Make Nursing Research a Part of Your Journey

Conducting and implementing nurse research is a collaborative effort. It takes a team of informed leaders, skilled analysts, and creative educators to create effective, evidence-based policies. Those interested in pursuing nurse research should consider The University of Tulsa’s online MSN program , which can prepare you to fill any one of those roles and more.

All of TU’s MSN students take classes on research and evidence-based practices. However, the program’s specialty tracks allow students to take their studies in multiple research-oriented directions. For instance, if you’re interested in collecting and interpreting clinical data, you can choose the Informatics and Analysis track. If you have a passion for public health policy, the Public Health and Global Vision track includes classes on population health and epidemiology.

Delivered in a flexible online format, this program can be a great option for working nurses and nontraditional students alike. To find out more, read about TU’s admission policies and request more information today.

Recommended Readings

A Nurse Educator’s Role in the Future of Nursing

How Global Health Nursing Supports Population Health

What Can You Do With an MSN?

Gallup, “Record High in U.S. Put Off Medical Care Due to Cost in 2022”

International Journal of Nursing Practice, “Nursing Crisis: Challenges and Opportunities for Our Profession After COVID‐19”

Journal of Pain Symptom Management , “Risk Factors Associated With Chemotherapy-Induced Nausea in the Week Prior to the Next Cycle and Impact of Nausea on Quality of Life Outcomes”

Mayo Clinic, Nursing

National Institute of Nursing Research, Scientific Strategy: NINR’s Research Framework

National Institute of Nursing Research, The National Institute of Nursing Research 2022-2026 Strategic Plan

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• Published: 05 September 2024

Exploring the use of social network analysis methods in process improvement within healthcare organizations: a scoping review

• Troy Francis 1 , 2 , 3 ,
• Morgan Davidson 1 ,
• Laura Senese 1 ,
• Lianne Jeffs 1 ,
• Reza Yousefi-Nooraie 4 ,
• Mathieu Ouimet 5 ,
• Valeria Rac 1 , 3   na1 &
• Patricia Trbovich 1 , 2   na1  

BMC Health Services Research volume  24 , Article number:  1030 ( 2024 ) Cite this article

Metrics details

Communication breakdowns among healthcare providers have been identified as a significant cause of preventable adverse events, including harm to patients. A large proportion of studies investigating communication in healthcare organizations lack the necessary understanding of social networks to make meaningful improvements. Process Improvement in healthcare (systematic approach of identifying, analyzing, and enhancing workflows) is needed to improve quality and patient safety. This review aimed to characterize the use of SNA methods in Process Improvement within healthcare organizations.

Relevant studies were identified through a systematic search of seven databases from inception - October 2022. No limits were placed on study design or language. The reviewers independently charted data from eligible full-text studies using a standardized data abstraction form and resolved discrepancies by consensus. The abstracted information was synthesized quantitatively and narratively.

Upon full-text review, 38 unique articles were included. Most studies were published between 2015 and 2021 (26, 68%). Studies focused primarily on physicians and nursing staff. The majority of identified studies were descriptive and cross-sectional, with 5 studies using longitudinal experimental study designs. SNA studies in healthcare focusing on process improvement spanned three themes: Organizational structure (e.g., hierarchical structures, professional boundaries, geographical dispersion, technology limitations that impact communication and collaboration), team performance (e.g., communication patterns and information flow among providers., and influential actors (e.g., key individuals or roles within healthcare teams who serve as central connectors or influencers in communication and decision-making processes).

Conclusions

SNA methods can characterize Process Improvement through mapping, quantifying, and visualizing social relations, revealing inefficiencies, which can then be targeted to develop interventions to enhance communication, foster collaboration, and improve patient safety.

Peer Review reports

Introduction

Adverse events, including medical errors, diagnostic errors, and preventable complications, continue to affect millions of patients globally, leading to severe morbidity, mortality, and substantial avoidable healthcare costs [ 1 , 2 ]. Among the many factors contributing to avoidable adverse events, breakdowns in communication have been identified as a leading cause [ 3 , 4 , 5 ]. Lapses in communication during care coordination and patient handoffs can lead to inadequate patient follow-up, delayed care, increased healthcare costs, and provider burnout, leading to an increased risk of adverse events [ 4 , 6 ].

Many studies have highlighted that investigating the underlying causes and consequences of poor communication is necessary to improve the delivery of high-quality care [ 3 , 4 , 6 , 7 ]. However, a large proportion of studies investigating communication in healthcare organizations lack the necessary understanding of social structures (interconnected relationships of social groups e.g., who speaks to who, for what purpose, using what mechanism) and coordination structures (e.g., how information gets transferred or transitioned between people or services) to make meaningful improvements and reduce adverse events [ 8 , 9 ]. For example, the surgical safety checklist (SSC) is a tool meant to enhance patient safety by coordinating care delivery and improving inter-professional communication [ 10 ]. Yet, many studies report conflicting results on the impact of the SSC due to a lack of mutual understanding of communication among team members (e.g., who is responsible for leading a specific checklist pause point) and coordination (e.g., what team members should be present during specific pause points) structures ( 11 , 12 , 13 ). Effective communication among healthcare providers is challenging due to the complex nature of tasks performed and the numerous healthcare providers embedded within hierarchical structures. While the effective use of Process Improvement or Quality Improvement (QI; framework to systematically improve processes and systems in healthcare) interventions rely on understanding the social interactions and relationships within organizations, little attention has been paid to how social networks can be used to improve the effectiveness of communication and coordination in healthcare.

A social network is a set of social entities, actors or nodes (individuals, groups, organizations) connected by similarities, social relations, interactions, or flows (information) [ 14 ]. Analyzing professional communication structures (e.g., observed formal advice-seeking or giving related to work situations) within healthcare organizations’ social networks is important in understanding how best to inform interventions by identifying which network structures promote or inhibit behavior change [ 15 ]. The use of social network analysis (SNA) can provide insight into the social relationships, interactions, and tasks involved within sociotechnical systems. SNA metrics are quantitative measures used to analyze the structure, relationships, and dynamics within social networks through quantifying network behavior [ 16 ]. Network metrics reflect centrality , which refers to a family of measures where each represent different conceptualizations of nodal importance within a network, and cohesion measures, which examine the extent to which nodes within a network are connected [ 14 , 17 ]. These metrics provide an understanding of the structure of social networks through identifying influential nodes, information flow, communities, and cliques [ 18 ]. SNA has been shown to improve professional communication and interprofessional relationships by revealing gaps in communication and identifying influential social entities and communication channels [ 14 , 15 , 19 ]. By indicating which social entities are effective in the flow of communication, organizations can leverage their skills to disseminate important information effectively and foster positive inter-professional relationships [ 19 , 20 ]. Additionally, through identifying gaps in communication between different teams or departments organizations can work to prevent misunderstandings, adverse events, and the duplication of efforts resulting in a more collaborative work environment with stronger interprofessional relationships [ 14 , 21 ]. Through understanding social networks, SNA can be effective in designing, implementing, and evaluating interventions needed to improve professional communication and coordination in healthcare [ 15 , 22 ].

The aim of this review was to characterize the existing literature to assess SNA methods ability to identify, analyze, and improve processes (Process Improvement) related to patient care within healthcare organizations.

The scoping review was conducted using Arksey and O’Malley’s modified six-step framework [ 23 , 24 ]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) standards were used to guide the reporting of this review [ 25 ]. The PRISMA-ScR checklist is shown in the Appendix.

Information sources and search strategy

In collaboration with a research librarian (JB), relevant studies were identified through a systematic search of the MEDLINE (Ovid), Embase, Psychinfo, AMED (Allied and Complementary Medicine), CINAHL, Cochrane Library and Web of Science databases from inception – 16 October 2022. The database search was supplemented with hand searching of reference lists of included reviews. Grey literature was searched using Google Custom Search Engine strategies to narrow search results and allow for more targeted results [ 26 , 27 ]. Searched websites included the International Network for Social Network Analysis, American Evaluation Association Social Network Analysis Technical Interest Group, and the International Sunbelt Social Networks Conference proceedings archives. The search strategy for the social network analysis concept was adapted from Sabot et al.’s systematic review of Social Network Analysis and healthcare settings [ 22 ]. Truncation search terms were used to search inclusive and key terms for these concepts can be found in the supplemental appendix.

Eligibility criteria

A screening checklist developed by Sabot et al., 2017 was modified to guide the review of this study [ 22 , 28 ]. A “no” response to any of the study inclusion criteria (Appendix) was a reason for exclusion from the scoping review. “Healthcare providers” were classified as physicians, physician’s assistants, nurses, midwives, pharmacists, pharmacy technicians, clinical officers, counselors, allied health professionals, and other individuals involved in professional networks (e.g., administrative support staff, management). “Professional communication” was defined as observed formal professional advice-seeking or giving related to hypothetical or actual work situations or patients [ 22 ]. Healthcare organizations were defined as a building or mobile enclosure in which human medical, dental, psychiatric, nursing, obstetrical, or surgical care is provided. Healthcare organizations can include but are not limited to, hospitals, nursing homes, limited care facilities, medical and dental offices, and ambulatory care centers [ 29 ]. Studies had to report the use of SNA in the design of the study (e.g., social network mapping, evaluation of network properties or structure, or analysis of network actors) [ 22 ]. Additionally, to be included studies were required to use systematic data-guided activities (e.g., aims and measures) to achieve improvement or use an iterative development and testing process (i.e., Lean Management, Six Sigma, Plan-Do-Study-Act (PDSA) cycles, or Root Cause Analysis) [ 30 , 31 ]. Studies where network relations were defined solely by patient sharing were excluded, as this only predicts person-to-person communication in a minority of instances [ 32 ]. Abstracts and conference proceedings were considered if details of their methodology and results were published. No limits were placed on study design, language, or publication period.

Study selection and screening process

Study selection and screening employed an iterative process involving searching the literature, refining the search strategy, and reviewing articles for study inclusion. The titles and abstracts of all identified references were independently examined for inclusion by three reviewers (T.F, M.D, and L.S) using the Covidence software platform for systematic reviews [ 33 ]. Full texts of potentially eligible studies were retrieved by the reviewers (T.F, M.D, and L.S), who determined study eligibility using a standardized inclusion screening checklist. Inter-rater reliability was assessed at each phase of the scoping review between reviewers and disagreements were resolved by consensus with input from a fourth author (L.J).

Charting the data

Data from eligible full-text studies was charted by the reviewers (T.F, M.D, L.S) independently using a standardized data abstraction form in Covidence to obtain key items of information from the primary research reports. Discrepancies among reviewers were resolved by consensus. The data abstraction form captured information on key study characteristics (e.g., author, year of publication, location of study, study design, aim of study, type of healthcare facility/provider), SNA-related information (e.g., SNA purpose, data collection methodology, software, SNA metrics) and reported on the implications of using SNA (e.g., social network mapping, assessment of network members or structures).

Collating, summarizing, and reporting the results

A narrative synthesis was performed to describe the study characteristics, SNA methodology, and SNA metrics. The stages of the narrative synthesis included: (1) developing the preliminary synthesis, (2) comparing themes within and between studies, and (3) thematic classification [ 34 ]. Detailed text data on SNA characteristics and implications were reviewed, re-categorized, and analyzed thematically. In line with our objectives, the thematic analysis focused on identifying SNA methods used to improve communication and coordination in healthcare organizations. To categorize the approaches, we conducted further distillation of overarching approaches. We took notes throughout the review and analysis stages, documenting emerging trends and ideas to facilitate further review and discussion among the review team. The extracted data was tabulated in descriptive formats and narrative summaries were provided.

The literature search generated 5084 potentially eligible studies after deduplication, of which 4936 were excluded based on title and abstract, leaving 148 full-text articles to be reviewed. The PRISMA-ScR flow diagram outlining the breakdown of studies can be found in Fig.  1 . Upon full-text review, 44 reports of 38 studies were included for data abstraction. Six studies [ 4 , 35 , 36 , 37 , 38 , 39 ] had multiple records and were truncated into single studies.

PRISMA-ScR flow diagram

Study characteristics

The characteristics of the included studies are shown in Table  1 . Many studies were recently published between 2015 and 2021 (26, 68%) and were primarily located in the United States (26, 68%). 67% of studies occurred within a hospital (25, 66%) and most studies (15, 39%) were set in Internal medicine (gastroenterology, oncology, cardiology, nephrology, respirology, telemetry, or acute care). Studies employed multidisciplinary healthcare providers, however many studies focused on physicians (endocrinologists, oncologists, plastic surgeons, neurologists, anesthesiologists, intensivists, generalists; 27, 71%) and nursing staff (registered nurse, nurse practitioner, practical nurse; nursing assistants; 27, 71%). Most studies employed an observational study design, with 5 studies utilizing longitudinal quasi-experimental design [ 40 , 41 , 42 , 43 , 44 ]. Five studies used mixed-methods designs [ 35 , 36 , 45 , 46 , 47 ] with integrated qualitative and quantitative data, and a further 6 studies used multi-method designs [ 48 , 49 , 50 , 51 , 52 , 53 ] using a combination of independent qualitative and quantitative data. Twenty-four studies reported using quantitative data only [ 3 , 4 , 6 , 40 , 41 , 42 , 43 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 ] and the remaining 2 studies used qualitative methods [ 71 , 72 ].

Table  2 provides an overview of the aims and findings of the included studies and Table  3 outlines the use of SNA methodology and reflects the data collection methods, software, and SNA metrics included in each study. A wide range of network visualization software was used with studies giving preferences towards UCINET [ 36 , 40 , 48 , 54 , 57 , 58 , 59 , 66 , 67 , 68 , 70 , 72 , 73 ], Organization Risk Analyzer (ORA) [ 4 , 55 , 74 , 75 ], and Open-Sourced R Software [ 42 , 49 , 53 , 63 , 65 , 76 ]. Five out of the 38 studies did not visualize their networks through social network mapping and only provided a descriptive assessment of network structures or analysis of network members [ 3 , 40 , 57 , 68 , 76 ]. Two studies did not explicitly report SNA metrics [ 47 , 61 ]. Table  4 provides a comprehensive breakdown of the SNA metrics selected in each study and their application to healthcare networks. There were many network metrics used throughout the studies, however, most studies primarily employed Degree Centrality, Betweenness Centrality, and Density. Twenty-six studies used Degree Centrality as a measure of reach and importance [ 3 , 4 , 6 , 35 , 36 , 41 , 43 , 44 , 45 , 46 , 48 , 49 , 51 , 54 , 55 , 56 , 57 , 58 , 59 , 62 , 63 , 64 , 65 , 67 , 69 , 70 ], 20 studies used Density to measure network cohesion [ 6 , 35 , 36 , 41 , 43 , 44 , 45 , 48 , 53 , 54 , 55 , 57 , 58 , 62 , 63 , 69 , 70 , 71 , 72 , 77 ], and 19 studies used Betweenness Centrality as a measure of influence and brokerage [ 3 , 4 , 36 , 44 , 45 , 46 , 49 , 51 , 52 , 55 , 56 , 57 , 59 , 60 , 62 , 63 , 65 , 66 , 69 ].

* Some articles were assigned to more than one category.

Listed in descending frequency, however “Other” is always at the bottom.

Application and findings of SNA

SNA has been used in healthcare to measure the number of connections (i.e., interactions, tasks), the centrality of providers (i.e., degree, betweenness, and closeness), and network cohesion (i.e., density, clustering). It has helped us to understand essential themes like organizational structure, team performance, and influential actors in healthcare.

a) Organizational Structure.

SNA has been used to better understand how organizational structures (e.g., management roles, groupings of tasks and employees) influence communication and coordination, thereby informing opportunities for improvement. Nine studies showed how SNA was used to redesign hospital organizational structures [ 35 , 36 , 41 , 45 , 46 , 53 , 66 , 69 , 72 ]. For example, Samarth et al. [ 69 ] applied SNA to improve the throughput of their surgical patients, which revealed a hierarchical network coordination structure in their post-anesthesia care unit (PACU) wherein the Charge Nurse channeled all communication downstream, thereby becoming a bottleneck resulting in patient delays. This led to a redesign of their organizational network to a more democratic structure where coordination was performed by an integrated information technology (IT) system which was available to all team members, reducing the dependence on the charge nurse [ 69 ]. Additionally, Alhaider et al. [ 52 ] demonstrated how SNA could be used to investigate system-wide communication in patient flow management and identify process improvement within the healthcare system. Applying SNA within the Distributed Situation Awareness (DSA) framework helped identify bottlenecks in patient flow and the roles that were most likely to experience communication or transaction overload while acquiring and disseminating situational awareness. The DSA model provided a characterization of patient flow and a blueprint for healthcare facilities to consider when modifying their organizational structure to improve communication and coordination. Spitzer-Shohat et al. [ 36 ] used SNA to understand how their organizational structure could help implement disparity reduction interventions to improve care. The SNA unveiled that their subregional management had a high degree of centrality (i.e., many connections), and as such, they were targeted to spread information about the interventions [ 36 ].

A specialized application of SNA involves identifying how IT can enhance or transform organizational communication and coordination. Three studies used SNA to understand how providers from different professions and units communicate across various modes (e.g., in-person, phone, electronic medical record) [ 4 , 48 , 69 ]. For example, SNA highlighted that IT could help improve communication efficiencies during in-person patient handoffs. More specifically, SNA showed that IT could support the redesign of the social network patterns by removing redundant communication exchanges and support emergent and non-linear information flow [ 4 , 69 ]. Six studies used electronic health records (EHR) data to map the network structure of professionals involved in care to show that improving the design of IT can support communication leading to more frequent information sharing among professional groups [ 6 , 47 , 51 , 56 , 60 , 63 ]. Nengliang et al. [ 56 ] demonstrated that EHR log data could be used within an SNA to map the network structure of all healthcare providers and examine the connectivity, centrality, and clustering of networks that emerged from interactions between providers who shared patients. In turn, this data revealed the dynamic nature of care teams and areas (inpatient and outpatient) for collaborative improvement [ 56 ]. Another study used SNA to help contrast low and high IT implementations; they found that the high IT sophistication care homes had more robust and integrated communication strategies requiring fewer face-to-face interactions between providers to verify orders or report patient status compared to the low IT sophistication nursing home [ 47 ].

b) Team Performance.

Sixteen studies used SNA to examine poor team communication and coordination by highlighting the inefficiencies in health networks [ 3 , 36 , 41 , 43 , 53 , 54 , 55 , 57 , 58 , 61 , 64 , 65 , 67 , 68 , 70 , 71 ]. SNA identified that these inefficiencies stem from: teams being overburdened due to workload [ 54 , 61 ], conflict between team roles [ 36 ], lack of leadership [ 43 , 58 ], and fragmented interprofessional relationships [ 57 , 65 , 70 ]. For example, poor team performance in hospital emergency departments has resulted in congestion and increased length of stay with patients having prolonged discharges. SNA allowed for an exploration of the possible causes of inefficiencies resulting in access blocks and determined that the number of healthcare providers and interactions between them, and the centralization of providers within the network affected the performance and quality of emergency departments [ 54 ]. Grippa et al. [ 3 ] used SNA and determined that the most efficient and effective healthcare teams focused more inwardly (internal team operation) and were less connected to external members. Additionally, SNA highlighted that effective teams communicated using only one or two mediums (e.g., in-person, email, instant messaging media) instead of dispersing time on multiple media applications.

SNA has been used to diagnose possible reasons for team inefficiencies and to identify potential design solutions to improve team performance [ 3 , 35 , 42 , 53 , 64 , 67 , 68 , 71 ]. A study used SNA to identify that some experienced staff (who frequently mentor other staff) may have too many connections (high degree of centrality), leading to interruptions or distractions and impacting performance and coordination [ 54 ]. However, a different study, identified that staff with a high degree of centrality have the benefit of improving team performance by leveraging their social networks to be change agents and lead others to replicate desired behaviors (e.g., when a provider may forget to implement a desired change but gets reminded by a team member) [ 62 ]. Lastly, analyzing network cohesion helped identify fragmentation and cliques in the network which may reflect a lack of collaboration and interprofessional relations. For instance, denser (more connections) communication networks with more clustering (groups of connections) are associated with more rapid diffusion of information. Additionally, the connections between providers in dense networks can provide social support (reinforcement) to team members that strengthen their commitment to follow desired behaviors and increase the likelihood that deviations from those actions will be noted by their peers [ 62 ].

c) Influential Actors.

SNA was used to identify influential actors who could act as brokers (an individual who occupies a specific structural position in systems of exchange) [ 3 , 49 , 64 ] who could become opinion leaders (an individual who holds significant influence over others’ attitudes/beliefs) [ 62 ], champions (an individual who actively supports innovation and its promotion/implementation) [ 40 ] or a change agent (an early adopter of an intervention who supports the dissemination of its use) [ 44 ] based off measures of social influence within a network. Studies showed that influential actors in social networks can inform behavioral interventions needed to improve professional communication or coordination [ 3 , 40 , 49 , 62 , 64 ]. For example, Meltzer et al. [ 62 ] used SNA to identify influential physicians to join a QI team and highlighted that having members with connections external to the team is most important when disseminating information, while within team relationships matter most when coordination, knowledge sharing, and within-group communication are most important. When creating an interdisciplinary team, betweenness centrality (node that frequently lies on the shortest path in a network) may be a useful network metric for prospectively identifying team members that may help to facilitate coordination within and across units / professional groups. Providers with a high betweenness have been found to be leaders and active participants in task-related groups [ 68 ]. Hurtado et al. [ 40 ] used SNA to identify and recruit champions who were used to deploy a QI intervention (safe patient handling education program) to advance safety in critical access hospitals. The champion-centered approach resulted in improved safety outcomes (increase in safety participation/compliance and decrease in patient-assist injuries) after one year. Additionally, Lee et al. [ 44 ] used SNA to assess the use of peer-identified and management-selected change agents on improving hand hygiene behavior in acute healthcare. No significant differences were reported between the two groups; however providers expressed a preference for hierarchical leadership styles highlighting the need to understand organizational culture before designing changes to the system.

This scoping review presents a comprehensive overview of the existing literature looking at the use and impact of SNA methodology on Process Improvement within healthcare organizations. Our search strategy included a wide range of databases and placed no restrictions on study design, language, or publication period. When examining the expanding body of literature represented in our identified 38 studies, SNA methods were used to detect essential work processes in organizations, reveal bottlenecks in workflow, offer insight into resource allocation, evaluate team performance, identify influential providers, and monitor the effectiveness of process improvements over time. By analyzing the communication and relationships between management roles, employee groupings, and task allocation, SNA provides insights that can help identify areas for improvement related to patient throughput, diffusion of information, and the uptake of technology (e.g., IT systems). Studies highlighted that healthcare team performance can be hampered by inefficiencies related to being overburdened due to workload, conflicts between team roles, lack of leadership, and fragmented interprofessional relationships. To address these inefficiencies, SNA can leverage network outcomes related to connectedness (e.g., degree, betweenness, closeness) and use knowledge of the network structure (e.g., density, clustering coefficient, fragmentation) to create targeted interventions to mitigate these problems. Additionally, inefficiencies in social networks can be mitigated by identifying influential actors who serve as change agents and can be utilized as opinion leaders or champions to improve the efficiency of information exchange and the uptake of behavioral interventions.

Comparison With Past Literature (Study Design and Data Collection).

Our review stands out from previous studies due to its unique focus on the application of SNA methods in Process Improvement within healthcare organizations. Our primary objective was to investigate how healthcare organizations utilize SNA techniques to improve system-level coordination and enhance the overall quality of care provided to patients. In their research study, Sabot et al. [ 22 ] aimed to investigate the various SNA methods employed to examine professional communication and performance among healthcare professionals. Their study delved into the diverse range of SNA techniques used to gain insights into the complex network dynamics and interactions among providers. In more recent studies, Saatchi et al. [ 78 ] focused on exploring the adoption and implementation of network interventions in healthcare settings. This study provided insights into the effectiveness of network interventions (in which contexts they are successful and for whom), their potential benefits (increased volume of communication), and the challenges associated with their adoption in practice. Additionally, Rostami et al. [ 79 ] focused on advancing quantitative SNA techniques and investigated the application of community detection algorithms in healthcare. This study offers a comprehensive categorization of SNA community detection algorithms and explores potential approaches to overcome gaps and challenges in their use. Previous reviews primarily included observational and cross-sectional study designs with no comparator arms, which made determining the value of using SNA methods difficult as there was no comparison of social networks over time and no comparable head-to-head data. Our review identified 5 quasi-experimental studies [ 40 , 41 , 42 , 43 , 44 ] which used longitudinal or pre-post study designs. In each of these studies SNA was used to review a system which delivered clinical care to identify sources of variation and areas for process improvement at an individual and organizational level. The quasi-experimental studies were published within the last 5 years, indicating that SNA methodology is still in development and opportunities for experimental and longitudinal study designs are forthcoming. Using experimental and longitudinal SNA methods would enable causal inference of healthcare interventions or policies leading to improved generalizability of results.

When performing SNA there is a variety of qualitative (interviews, focus groups, observations) and quantitative (surveys, document artifacts, information systems) methods that researchers can use to map social networks, assess network structures, and analyze team actors. However, previous literature reviews have outlined an overreliance on descriptive SNA methods, which lack the contextual factors needed to interpret how a network reached a given structure. There has been a growing body of evidence advocating for the use of mixed-method social network data collection [ 80 ]. Our review has highlighted an increased uptake of mixed-method (integration of qualitative and quantitative methods and data) and multi-method (independent use of quantitative and qualitative methods) SNA study designs [ 81 ].

Knowledge Gaps and Future Research.

This scoping review highlights many practical uses of SNA; however, within most studies, little attention has been paid to leveraging SNA theory to help explain why networks have the structures they do [ 21 ]. For example, social boundaries between professional groups (e.g., Physicians, Nurses, Pharmacists) can inhibit the development of interprofessional networks though the creation of cliques leading to strong communication and coordination within groups, but fragmented communication across professional groups [ 21 , 82 , 83 ]. A potential explanation for the scarcity of studies assessing the reasons behind the structures of networks could be attributed to the primarily quantitative SNA methods used. Few studies used a qualitative or mixed-method design, indicating a limited understanding of the contextual factors associated with social networks. SNA can reveal the informal structures within organizations and underscores the importance of understanding that not all influential relationships between healthcare providers are found on formal organizational charts, and that informal networks can significantly influence communication and coordination [ 84 ]. The lack of robust study designs (mixed-method or multi-method) may also reflect the use of SNA by researchers more so as a technique than a methodology with theoretical underpinnings.

The value of using SNA to inform research and disseminate evidence-based interventions and policies has been discussed in the literature extensively. However, very few studies have used research on complex systems and network theory to examine how HCWs can act as change agents, interacting within and between hubs in organizations to disseminate knowledge [ 85 ]. Future research should apply complexity science to SNA to reconceptualize knowledge translation and think of the process as interdependent and relationship-centric to support sustainable translation [ 85 ]. Only a small group of included articles have highlighted how leveraging influential actors as change agents such as opinion leaders or champions can be advantageous in improving professional communication or coordination [ 3 , 40 , 44 , 49 , 62 , 64 ]. This review identified two studies [ 40 , 44 ] which utilized SNA and a champion-centered approach to support the successful implementation of a QI intervention resulting in improved safety outcomes. The use of champions is very prevalent in healthcare; however, success rates vary widely, likely due to the poor selection of champion candidates or organizational culture [ 40 , 44 ]. In many cases healthcare workers selected to be champions are volunteered and do not hold enough social influence to change the behaviors of their colleagues. In the future SNA methods should be used to identify influential champions or opinion leaders embedded within their social networks who can influence knowledge transfer and facilitate coordination leading to process improvements.

Future research should identify how SNA methods can leverage health informatics and the large amounts of data stored within healthcare organizations. Even though past studies have used SNA to enhance organizational communication and coordination using IT [ 47 , 56 , 69 ], applying SNA to artificial intelligence and machine learning (ML) algorithms has not received much attention [ 86 ]. Integrating ML algorithms into community detection techniques has showcased the diverse ways SNA can be utilized in healthcare to monitor disease diagnosis, track outbreaks, and analyze HCW networks [ 79 ].

Limitations of the Review.

This review has some limitations that should be acknowledged. First, we excluded studies of provider friendship networks, which theoretically may have contained some professional communication. Secondly, we excluded studies where network relations were defined solely by patient sharing, as this has only been shown to predict person-to-person communication in a minority of instances. Lastly, studies were required to incorporate a Process Improvement component. Different terms were used to describe Process Improvement in the literature, making it challenging to devise a search strategy that would yield sufficient articles for review while also utilizing SNA methods. As a result, studies that utilized SNA methods but did not explicitly examine a process or system for delivering clinical care to identify sources of variation and areas for improvement were excluded.

SNA methods can be used to characterize Process Improvements through mapping, quantifying, and visualizing social relations revealing inefficiencies, which can then be targeted to develop interventions to enhance communication, foster collaboration, and improve patient safety. However, healthcare organizations still lack an understanding of the benefit of using SNA methods to reduce adverse events due to a lack of experimental studies. By emphasizing the importance of understanding professional communication and coordination within healthcare teams, units, and organizations, our review underscores the relationship between organizational structures and the potential of influential actors and emerging IT technologies to mitigate adverse events and improve patient safety.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

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Acknowledgements

The authors would like to thank Joanna Bielecki for her assistance in developing the search strategy and Sonia Pinkney for her valuable feedback and suggestions in refining this manuscript.

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Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

Troy Francis, Morgan Davidson, Laura Senese, Lianne Jeffs, Valeria Rac & Patricia Trbovich

HumanEra, Research and Innovation, North York General Hospital, Toronto, ON, Canada

Troy Francis & Patricia Trbovich

Program for Health System and Technology Evaluation, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada

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Department of Public Health Sciences, University of Rochester, New York, USA

Reza Yousefi-Nooraie

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Francis, T., Davidson, M., Senese, L. et al. Exploring the use of social network analysis methods in process improvement within healthcare organizations: a scoping review. BMC Health Serv Res 24 , 1030 (2024). https://doi.org/10.1186/s12913-024-11475-1

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A Quasi-Experimental Study of a Basics of Evidence-Based Practice Educational Intervention for Health and Social Care Professionals

Hanna-leena melender.

1 Department of Social and Health Care, VAMK University of Applied Sciences, Vaasa, Finland

Susanne Salmela

2 Research and Development Unit, Vaasa Central Hospital, Vaasa, Finland

3 School of Technology and Innovations, University of Vaasa, Finland

Associated Data

Supplemental material, sj-pdf-1-son-10.1177_2377960820925959 for A Quasi-Experimental Study of a Basics of Evidence-Based Practice Educational Intervention for Health and Social Care Professionals by Hanna-Leena Melender, Susanne Salmela and Bernd Pape in SAGE Open Nursing

Education is one of the central interventions to promote evidence-based practice (EBP) in service organizations. An educational intervention to promote EBP among health and social care professionals was implemented in a Finnish hospital. The aim of this study was to explore the outcomes of an educational intervention, focusing on the basics of EBP for health and social care professionals, using a quasi-experimental study design. The data were collected with a questionnaire before, immediately after, and 6 months after the education ( n  = 48). The data were analyzed with descriptive statistics and nonparametric tests. Immediately after the education, an increase was found in the EBP knowledge of participants, in participants’ confidence in their own ability to conduct database searches and read scientific articles, and in the number of participants using databases at work. Six months after the education, improvements were still found between the first and the third measurement in the participants’ knowledge and confidence in their own ability to conduct database searches and read scientific articles. The number of those who had made an initiative about a research topic regarding the development of their own work had increased from the first to the third measurement. The educational intervention produced a statistically significant improvement on most of the areas evaluated. Significant improvements were often found even 6 months after the education was finished. However, the low completion rate and a quasi-experimental before and after design limit the conclusions that can be derived from this study.

Evidence-based practice (EBP) is “a lifelong problem-solving approach to how healthcare is delivered that integrates the best evidence from high-quality studies with a clinician’s expertise and also a patient’s preferences and values” ( Melnyk, 2017 , p. 8). EBP improves the quality and safety of health care and enhances health outcomes, decreases geographic variation in care as well as reduces costs ( Melnyk, 2017 ). Although positive attitudes from nurses toward EBP have been reported, there are also deficiencies associated with the consistent implementation of EBP ( Duffy et al., 2015 ; Melnyk et al., 2012 , 2018 ). One of the main barriers for that is a lack of EBP competencies ( Duffy et al., 2015 ; Fairbrother et al., 2016 ).

Educational interventions promoting EBP are intended to increase learners’ competence concerning EBP and thus support lifelong learning ( Ilic & Maloney, 2014 ). The body of evidence to guide educators on how to teach EBP to health professionals has remained quite modest. Therefore, there is a need for further research on the effectiveness of EBP educational interventions for health professionals ( Häggman-Laitila et al., 2016 ; Ilic & Maloney, 2014 ; Melnyk et al., 2018 ). It has also been stated that that in further studies, attention should be paid to the detailed descriptions of the interventions and their implementation ( Häggman-Laitila et al, 2016 ; Ilic & Maloney, 2014 ). This study aimed to address these challenges.

Literature Review

The Classification Rubric for EBP Assessment Tools in Education (CREATE) recommends a common taxonomy to develop an EBP assessment tool. According to this, the assessment of EBP learning should focus on seven areas: knowledge, skills, attitudes, self-efficacy, behaviors, learners’ reactions to the educational experience, and benefits to the patient ( Tilson et al., 2011 ). Out of these, the first six were addressed in this study. In the following, earlier research is examined according to these areas.

When implementing educational interventions on EBP for nurses, EBP knowledge has been assessed either with a knowledge test or the participants have been invited to self-evaluate their EBP knowledge. With a test, Saunders et al. (2016) found that after education, nurses’ knowledge improved both in the EBP education group and the research utilization education group. In studies by Chang et al. (2013) and Reviriego et al. (2014) , a knowledge test showed an improvement of knowledge on critical appraisal after education. In self-evaluations, Mollon et al. (2012) and Moore (2017) did not find any improvements after education, whereas in studies by Allen et al. (2015) and Ramos-Morcillo et al. (2015) , self-evaluation of knowledge showed improvement after education.

Evaluations of nurses’ EBP skills in educational interventions have been subjective, as the participants have been invited to self-evaluate their skills with a questionnaire. In such evaluations, no improvement in skills was found by Mollon et al. (2012) and Moore (2017) . However, in a study by Ramos-Morcillo et al. (2015) , the nurses’ skills had improved after education, and improvement in most critical appraisal competencies was found by Billingsley et al. (2013) .

When evaluating attitudes toward EBP, Mollon et al. (2012) , Ramos-Morcillo et al. (2015) , Moore (2017) , and Friesen et al. (2017) found no statistically significant improvements, whereas Snibsøer et al. (2017) found positive changes in nurses’ beliefs about EBP after education. Brown et al. (2011) found that at least 80% of nurses were excited about nursing research, valued reading it, and were interested in using it already before education; after education, there were no changes in attitudes. However, the percentage of nurses who would initiate a nursing research project increased from 26% to 34%.

Self-efficacy as an outcome has been addressed in studies by Chang et al. (2013) , Saunders et al. (2016) , and Royer et al. (2018) , who all found that nurses’ confidence in their skills improved after EBP education. However, in the study by Royer et al. (2018) , the self-efficacy scores between the end of the program year and 1-year follow-up did not differ significantly.

Nurses’ EBP behaviors have been studied by asking nurses about their practices before and after an EBP education. Snibsøer et al. (2017) found a statistically significant improvement for 8 of the 18 items measuring EBP implementation after the educational intervention, while Friesen et al. (2017) found for 6 of the items. In a study by Levin et al. (2011) , improvements in EBP implementation in an experimental group compared with a control group were found, whereas Mollon et al. (2012) , Ramos-Morcillo et al. (2015) , and Moore (2017) did not find any statistically significant improvements in EBP behaviors among nurses after education.

The learners’ reactions to the EBP educational experience were evaluated with a questionnaire ( Billingsley et al., 2013 ) or several questionnaires ( Reviriego et al. 2014 ). Both studies showed that nurses were mainly satisfied with their educational experiences. Participants in the program to educate and engage staff in the EBP process ( Royer et al., 2018 ) answered open-ended questions and reported satisfaction with most elements of the education; however, some weaknesses were also identified.

To sum up, evaluations of the outcomes of EBP educational interventions in earlier studies have varied from objective testing to subjective self-evaluations. The studies have shown differing results regarding EBP knowledge, skills, attitudes, self-efficacy, and behavior. The learners have mainly been satisfied with their educational experience.

In a central hospital in Western Finland, the action and economic plan of the hospital for year 2016 included a strategic goal to ensure that the competence of nursing staff would be systematically developed. A new tailored educational intervention regarding EBP for nurses and other professionals within health and social care was chosen for the strategy because the earlier developed interventions were either not suitable for the purposes of the strategy or the reports did not describe them in sufficient detail to support the choosing of them. Moreover, the strategy was to also employ objective evaluation methods and, thus, new evaluation strategies, which were tailored and utilized for the purposes of this study.

Aim of the Study

The aim of this study was to explore the outcomes of an educational intervention, focusing on the basics of EBP for health and social care professionals, using a quasi-experimental study design. The following were the research questions:

• Does the educational intervention have an effect on the EBP knowledge, attitude, self-efficacy, and behavior of the health and social health professionals participating in the education?
• What are the participants’ reactions to the educational experience after the educational intervention?
• What are the participants’ skills of EBP after the educational intervention?

Educational Intervention

The educational intervention is described in Table 1 , based on the Guideline for Reporting Evidence-based practice Educational interventions and Teaching checklist ( Phillips et al., 2016 ). The educational intervention conformed to the EBP competencies on a bachelor’s level ( Melnyk et al., 2014 ). The intervention was designed by the first two authors.

Description of the Educational Intervention.

Note . ECTS = European Credit Transfer System; PICO = Patient population, Intervention, Comparison, Outcome.

According to the strategy of the hospital, the first group to be educated would be the nurse leaders working as head nurses or assistant head nurses because research has shown that leaders have an important position in the promotion of EBP among nurses ( Stetler et al., 2014 ). All 108 head nurses and assistant head nurses of the hospital were invited to participate in the educational intervention. Information about the education was presented at a meeting of the hospital nurse leaders. Nursing directors individually encouraged the head nurses and assistant head nurses of their own area of responsibility to participate. In case one did not participate, another nurse from the unit could substitute her/him. Moreover, other health-care professionals and social workers had an opportunity to participate. All in all, the number of participants in the education was 83. The education was implemented in two rounds: The first round (32 participants) was implemented in Autumn 2016 and the second (51 participants) in Spring 2017.

Data Collection and Sample

The data were collected at three time points: before the educational intervention ( n  = 83), immediately after the education was finished ( n  = 82; learners’ feedback only at this phase), and 6 months after the education was finished ( n  = 48). Ethical questions are presented in Supplemental material.

The data were collected by a self-administered questionnaire developed by the researchers. A new instrument was developed because existing instruments did not cover all the topics that were of interest in this study. Such topics were, for example, certain organization-specific topics associated with the strategy of the hospital and some topics included in the knowledge test which were also included in the learning contents of the education. The content of any validated knowledge test did not suit for the purposes of this study. Moreover, validated instruments have many items for each category measured in this study, and we intended to keep the instrument short and simple, to make answering more attractive for the study participants. As a framework for the questionnaire, the CREATE by Tilson et al. (2011) was used. The instrument was pretested among a group of 15 masters’ students from the Development and Management of Social and Health-Care Services program at the first author’s university. Based on the pretest, the wording of some questions was clarified. The questionnaire was presented on paper.

For assessing knowledge, a 15-question knowledge test was developed. It was possible to get one point for each right answer. The knowledge test points (max. 15) reached by each participant constituted Variable 1 ( Table 2 ). The questions of the knowledge test were related to whether there was any legislation about EBP in Finland; what kind of databases are PubMed, CINAHL, Medic, Cochrane, and Joanna Briggs Institute databases; what do the concepts keyword , subject heading , Boolean operator , and open access mean; which organization develops and publishes nursing clinical guidelines in Finland; and whether they are available for free. Moreover, there were items asking about which organization translates the Joanna Briggs Institute Best Practice Recommendations into the Finnish language and whether the respondent’s own working organization provides the Joanna Briggs Institute database and the Cochrane database for the use of the staff. There were either two or four answering options for each question, of which one was right.

Repeated Measurement Test Results (unadjusted p-values significant at 5% after Bonferroni adjustment are provided in bold letters).

a A value of p  < .0167 was considered statistically significant at alpha = .05 (Bonferroni adjustment).

Attitudes were assessed with one question (Variable 2 in Table 2 ), asking about the participant’s view on the importance of the acquisition of scientific knowledge to constitute the basis of the work on a Likert scale of 1 to 3, options ranging from no importance (1) to high importance (3). Self-efficacy was evaluated with two questions, asking participants to evaluate her/his own competence on database searching (Variable 3 in Table 2 ) and on reading a scientific article (Variable 4 in Table 2 ) on a Likert scale of 1 to 3, options ranging from poor (1) to good competence (3). The Likert scale was used in the attitude question and in the questions where the respondents self-evaluated their own competence, as it is a suitable scale for questions measuring attitudes and evaluations ( Polit & Beck, 2012 ).

Behaviors were assessed with seven questions (Variables 5 to 11 in Table 2 ), asking whether the participant had taken different actions regarding the implementation or promotion of EBP at work on a dichotomous scale (yes/no). The dichotomous scale was used in the measurement of behaviors, as we were more interested in the facts ( Polit & Beck, 2012 ) regarding whether the respondent had done something that presents an action of EBP rather than how often or how much it had been done. Learners’ reactions to the educational experience were evaluated immediately after the education with five questions on a Likert scale ( Polit & Beck, 2012 ) of 1 to 3 ( Table 3 ).

Learners’ Reactions to the Educational Experience.

Benefits to the patient were not evaluated because the participants of the study represented many different units of the hospital, and it was not possible to organize the measurement of any patient outcomes.

EBP skills were evaluated separately by means of a given assignment in which the participants formulated a clinical question, searched for research evidence in databases, presented their search strategies, and prepared a PowerPoint presentation to be used in a public seminar in the hospital where they presented the evidence found (see Table 1 ). As for searching for research evidence, the participants’ skills in all the steps of the search were evaluated. The steps were as follows: (a) finding the suitable main concepts in Finnish and translating them into English, (b) choosing the corresponding subject headings, (c) using Boolean operators, (d) limiting the search, (e) examining the matches, and (f) obtaining the full texts ( Melender & Maijala, 2018 ). The instructors evaluated the assignments. The grades were passed or failed .

Data Analysis

Statistical analyses were performed using SPSS for Windows, Release 23.0. To describe the data, frequency and percentage distributions of the learners’ feedback variables and means of the other variables were calculated. The standard tool for statistical analysis in this setup with more than two dependent responses from the same respondents over time would have been an analysis of variance for repeated measurements. However, because analysis of variance requires the observations to be normally distributed at all time points and ours were not, we had to resort to nonparametric tests as described later and presented in Table 2 .

We first assessed overall significance with the Friedman test for Likert scale items and the Cochran test for dichotomous data, which are generally the most frequently used nonparametric tests in the analysis of repeated measurements. When a significant difference was found, we followed up with pairwise Wilcoxon signed-rank tests for Likert scale items and McNemar tests for dichotomous data. Again, we had to refrain from using pairwise t tests, as our observations were not normally distributed. In addition, because multiple testing inflates the risk of finding spurious significant results (type I error rates), we applied a Bonferroni correction by dividing the conventional significance level of 5% by the number of possible tests between 3 time points. Hence, we deemed differences between measurements significant only when the p value for the corresponding test fell below 1.67%.

Follow-Up Data

The final follow-up data reported in this article consisted of the responses of the 48 participants who completed and returned the questionnaire at all data collection points. Of the participants, 43 were head nurses or assistant head nurses, and five were other health and social care professionals. The flow diagram of participants through the study is presented in Figure 1 .

Flow diagram of Participants.

Effects of the Educational Intervention on the EBP Knowledge, Attitude, Self-Efficacy, and Behavior

Table 2 shows the means of the variables and the statistical tests applied. Immediately after the education was finished, the results of the knowledge test (Variable 1) were statistically significantly better, on average, than before the education. The mean at the third measurement point was also significantly better than before the education.

As for self-efficacy (Variable 3 and 4 in Table 2 ), the Cronbach’s alpha value for the section was .832. The confidence that the participants had in their ability to conduct database searches (Variable 3) had significantly increased, on average, from the first measurement to the second and the third measurement, whereas it had significantly decreased from the second to the third measurement. In addition, the confidence that the participants had in their ability to read scientific articles (Variable 4) had significantly increased, on average, from the first measurement to the second and the third measurement.

Behaviors were measured with Variables 5 to 11 ( Table 2 ), and the Cronbach’s alpha value for the section was .641. The percentage of participants using the Medic database at work (Variable 5) had statistically significantly increased from the first measurement (28%) to the second (64%) and the third measurement (60%). The number of participants using the PubMed database at work (Variable 6) had significantly increased from the first measurement (38%) to the second (69%) and the third measurement (65%). The number of participants using the CINAHL database at work (Variable 7) had significantly increased from the first measurement (27%) to the second (67%); at the third measurement point (48%), it had significantly decreased, however, and the difference between the first and the third measurement points was no longer significant. The percentage of those who had made an initiative about a research topic regarding the development of their own work in their own working unit (Variable 9) had significantly increased from the first (29%) to the third measurement (56%). There were no statistically significant differences between the measurement points in how important the participants found the acquisition of scientific knowledge to constitute the basis of their work on a scale of 1 to 3 (Variable 2); if scientific articles were used at work (Variable 8) (the percentages of the users in corresponding measurement points were 90%, 88%, and 92%); if students were commissioned to conduct database searches during their clinical practice (Variable 10) (the percentages of those who had commissioned were 42%, 40%, and 44% in corresponding measurement points); and if students were given topics for the thesis (Variable 11) (the percentages of those who had given topics were 52%, 60%, and 58% in corresponding measurement points).

Participants’ Reactions to the Educational Experience After the Educational Intervention

As for learners’ reactions to the educational experience ( Table 3 ), the Cronbach’s alpha value for the section was .639. Of the respondents, slightly more than one third found the education clearly significant from the point of view of their professional development, and two thirds found it somewhat significant. The contents of the education had been found to be clearly relevant by three quarters. Three quarters stated that the interactive lectures had supported their learning well. As for database-searching practices, almost four of five stated that they had supported learning well. Slightly more than four of five stated that the given assignment had supported their learning well.

Participants’ Skills of EBP After the Educational Intervention

EBP skills were evaluated by means of a given assignment. All the participants passed it; all were able to show an acceptable level of skills in formulating a clinical question, searching for research evidence in databases, presenting their search strategies, and presenting the evidence found.

Consideration of the Findings

The first research question focused on the effects of the educational intervention on the EBP knowledge, attitude, self-efficacy, and behavior. The knowledge test results had statistically significantly improved. Improvements in EBP knowledge after the education have been found also in many other educational interventions ( Allen et al., 2015 ; Chang et al., 2013 ; Ramos-Morcillo et al. 2015 ; Reviriego et al., 2014 ; Saunders et al., 2016 ).

There were no statistically significant differences regarding attitudes between the means of the responses at different data collection points. This was not, however, surprising because the attitudes were so positive already at the first data collection point. A similar result was found also by Brown et al. (2011) . However, there were many dropouts in this study, and it is possible that those who responded to all data collection points may have had a more positive attitude compared with the dropouts.

The assessment of self-efficacy showed an improvement of confidence among the participants, from the first data collection point to the second one, in their own ability to conduct database searches and to read scientific articles. An interesting result is that participants’ confidence in their own ability to conduct database searches had statistically significantly decreased from the second data collection point to the third one. A quite similar result was found by Royer et al. (2018) . A possible explanation for the result of our study is that after the end of the education, during the 6 months before the last data collection point, the participants may not have conducted as many database searches as they did during the education. Because they had not practiced for a long time, they might have been unsure if their abilities had remained. They also might have become more self-critical over time. Based on the results of this study and the results of Royer et al.’s (2018) study, it can be stated that the retaining of professionals’ self-efficacy in EBP after education is a future challenge when implementing educational interventions aiming to promote EBP in health and social care organizations.

As for EBP behaviors, the number of participants using databases at work had increased. For Medic and PubMed, improvement since the first data collection point occurred during the whole follow-up. However, the amount of CINAHL use had decreased up to the last data collection. In earlier research, Levin et al. (2011) found improvements in EBP implementation, whereas Mollon et al. (2012) , Ramos-Morcillo et al. (2015) , and Moore (2017) did not find any statistically significant improvements in EBP behaviors among nurses after education.

The number of participants who had made an initiative about a research topic regarding the development of their own work had increased. Quite similarly, in a study by Brown et al. (2011) , the number of nurses who would initiate a nursing research project increased after EBP education. Snibsøer et al. (2017) found that the participants of an EBP education read and critically appraised a clinical research study more often after education. In this study, there were no statistically significant differences between the measurement points regarding whether scientific articles were used at work. This was not surprising because the percentage of the users was already high at the starting point.

There were no differences regarding whether students were commissioned to conduct database searches during their clinical practice and if they were given topics for their thesis. The percentage of the former was less than 50%, and the percentage of the latter was 60% or less in all measurement points. Earlier research has shown that when nursing students’ learning has been connected with the development of EBP at clinics, the results have been positive for both ( Dobalian et al., 2014 ). These actions are important in the promotion of EBP and those who have competencies in EBP are in the frontline to do these actions. This could mean, for example, giving database searching tasks to student nurses when mentoring them during their clinical education.

The second research question focused on the participants’ reactions to the educational experience. The participants were quite satisfied with the education, as has been found also in earlier studies ( Billingsley et al., 2013 ; Reviriego et al., 2014 ; Royer et al., 2018 ). Most of the participants in this study found the education only somewhat significant for their professional development. However, most of them found the content of the education clearly relevant (also Royer et al., 2018 ), which implies that the content met the learning needs of most participants well. In addition to nurses, there were also representatives of some other health and social care professional groups among the participants of this educational intervention, as has also been in the study by Royer et al. (2018) , where the participants were mainly satisfied with the program. Interdisciplinary educational interventions on EBP are recommendable to ensure that all parts of the health and social services are based on the best evidence and because the patient care is carried out as interdisciplinary teamwork.

The third research question focused on the participants’ skills of EBP. All participants passed the given assignment by which EBP skills were evaluated. Because we did not conduct a pretest on skills before the education, it was not possible to evaluate how much their skills had averagely improved during the education. In future, a pretest on skills including numerical grading could be useful to show the development of EBP skills during the education. Mollon et al. (2012) , Billingsley et al. (2013) , Ramos-Morcillo et al. (2015) , and Moore (2017) reported self-evaluations by nurses of their EBP skills in educational interventions, which are subjective and, as such, are not comparable with this study where the evaluation was made by instructors.

Benefits to the patient were not evaluated in this study, although it has been recommended by Tilson et al. (2011) . This was because the participants presented many different units of the hospital. Organizing an evaluation of benefits to the patient would not have been possible in this study and conducting such studies can be seen as another future challenge of educational interventions aiming to promote EBP, as has been stated also by Häggman-Laitila et al. (2016) . Organizing such evaluation could be easier in a study setting of, for example, only one clinic with a specialty of its own.

Validity and Reliability of the Study

The educational intervention conformed to the EBP competencies on a bachelor’s level ( Melnyk et al., 2014 ), which strengthened the intervention. Häggman-Laitila et al. (2016) found in their review that the contents of the EBP educational interventions for nurses had not always included all the steps of EBP. In our intervention, all the EBP steps presented by Melnyk et al. (2014) were included. The use of the Guideline for Reporting Evidence-based practice Educational interventions and Teaching checklist in the reporting of the intervention enhances validity, as it is a specific validated reporting guideline designed to provide a framework for the consistent and transparent reporting of educational interventions regarding EBP ( Phillips et al., 2016 ).

The data were compiled by a new instrument that had not been used in previous studies, which is a limitation of this study. As a strength, the instrument was structured using the CREATE taxonomy, which has been developed by a specialist group ( Tilson et al., 2011 ) and which covers seven areas of evaluation of EBP educational interventions, out of which five were used as a framework for the questionnaire and one was addressed with a given assignment. The content of the questionnaire was partly based on a literature review and was pretested, which strengthened its validity.

As for reliability, Cronbach’s alpha values were calculated for the self-efficacy, behavior, and learners’ reactions to the educational experience section. For the first mentioned, the value was acceptable ( Field, 2009 ).

The sample size of this study was small, which is a limitation. There were many dropouts, despite the participants of the education being informed about the follow-up study and the importance of it at several stages. Moreover, reminders about responding were sent to all. It may be possible that after a 6-month period since the end of the education, answering the query was no longer deemed important, or in busy working environments, some simply might have forgotten to answer.

A further limitation is that this was a quasi-experimental before and after design, and there was no control group in this study. Use of such a control group would have strengthened the study design.

The educational intervention produced statistically significant improvement on most of the areas evaluated. Significant improvements were often found even 6 months after the education was finished. However, the low completion rate and a quasi-experimental before and after design will limit any conclusions that can be derived from this study. Challenges for future research are using strong study designs, such as randomized controlled trials, and measuring benefits to the patient. Moreover, the retaining of professionals’ self-efficacy in EBP after an EBP education has finished is a challenge in the development of future educational interventions aiming to promote EBP in health and social care organizations.

Supplemental Material

Acknowledgments.

The authors wish to thank all participants of the study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Hanna-Leena Melender https://orcid.org/0000-0003-4535-282X

Supplemental material

Supplemental material for this article is available online.

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• Open access
• Published: 04 September 2024

Comparison of professional competency and anxiety of nursing students trained based on two internship models: a comparative study

• Roya Dokoohaki 1 ,
• Masoume Rambod   ORCID: orcid.org/0000-0002-7334-9364 1 ,
• Nilofar Pasyar 1 ,
• Ali Mohammad Parviniannasab 2 ,
• Maryam Shaygan 1 ,
• Majid Najafi Kalyani 1 ,
• Zinat Mohebbi 1 &
• Azita Jaberi 1  

BMC Medical Education volume  24 , Article number:  968 ( 2024 ) Cite this article

Metrics details

Improving the professional competency of nursing students during the internship is critical. This study aimed to compare the professional competency and anxiety of nursing students trained based on two internship models.

This is a two-group posttest-only quasi-experimental design study. One hundred nursing students who passed internship models A (a previous internship model) and B (an intervention with more educator support and a more planned and programmed process) were randomly enrolled in this study. Internship model groups A and B were conducted for the students in semesters 7 and 8. The outcomes assessed in both groups were “The Competency Inventory for Registered Nurses” and Spielberger “State-Trait Anxiety Inventory”. T-test and MANOVA were used to analyze the data.

The mean scores of competency were 134.56 (SD = 43.23) and 160.19 (SD = 35.81) for the nursing students in the internship model groups A and B, respectively. The mean scores of nursing students’ anxiety were 92.14 (SD = 15.36) and 80.44 (SD = 18.16) in the internship model groups A and B, respectively. MANOVA test showed a significant difference between the groups regarding professional competency (F = 10.34, p  = 0.002) and anxiety (F = 11.31, p  = 0.001).

Conclusions

The internship model group B could improve the professional competency of nursing students to a great extent and they experienced mild anxiety; it is suggested that this intervention should be done for nursing students. Conducting more studies to evaluate the effect of this model on the nursing students’ competency and anxiety after graduation and as a novice nurse is suggested.

Peer Review reports

Introduction

Increasing clinical setting complexity necessitates further attention to nursing students’ competency [ 1 ]. The 7th and 8th semesters, when students spend more time in clinical environments, are one of the best times for improving nursing students’ competency. The use of clinical models, including internship, may be useful at this time. In the internship period, nursing students are directly supervised by the Nursing Unit Managers (NUMs) and clinical nurses and indirectly by the academic professor as a supervisor [ 2 ].

Internship, as an education model, was beneficial for the students, teachers, and patients. It not only improved health preservation but also increased the nursing students’ skills [ 3 ]. In the internship model, efforts were made to achieve clinical competency [ 2 ]. It improved nursing students’ knowledge, skills, and attitude [ 4 ]. It allows the knowledge acquired during the entire course to be (re) evaluated so that the professional competence is improved. Moreover, the teaching-learning methods are built according to critical pedagogy [ 5 ]. The students practiced self-management and tried to control the situations and stress [ 2 ]. It was mentioned that it improved professional identity and self-efficacy [ 6 ]. This model of education led to nursing students’ interaction with staff nurses and invisible evaluation [ 7 ]. It also reduced the gap between theory and practice [ 8 ] and increased nursing students’ process-based performance [ 9 ]. Moreover, it developed coping strategies for workplace adversities [ 6 ]. A study on the internship of community health nursing showed that service-based learning was effective in improving nursing students’ health education competencies and its subscales including skill, knowledge, community presence, attitude, and professional preparation [ 10 ].

Although this model of education in clinical setting has some advantages, it has some challenges such as lack of support and difficult planning [ 7 ]. Researchers reported that anxiety and low self-confidence in clinical competence settings were the challenges in nursing students’ internship period [ 11 ]. Lack of self-confidence caused anxiety and fear [ 11 ]. During this period, students showed anxiety with symptoms such as nervousness, fear, frequent urination, hand and foot tremors, panic, somatic pain, palpitation, facial flushing, sleep disturbance, etc. [ 11 ].

Considering the effects of the internship program in other countries and Iran, the researchers evaluated the difference between the existing program in Shiraz (nursing students’ internship model A) and other parts of the world. The researchers also raised the question of how to improve the nursing students’ professional competency during the internship and how to reduce their anxiety. In the comparison of the running program (nursing student’s internship model A) with the other countries, there were differences. The first one was the duration of the program that was about 12 weeks. Secondly, the students were not full-time employees in the clinical environment, and they left the ward at 1:00 PM. Next, they were only oriented to general information about the program and did not receive basic nursing trainings. In addition, nursing students were not paid during the course and insured.

Literature review showed that in the nursing students’ internships, exploitation and lack of incentive were the barriers to success in this program [ 12 ]. On the other hand, support, self-efficacy, internship structure, and setting were the factors that affected the students’ adjustment [ 13 ]. Work experience, environment, and critical thinking were the factors effective in development of nursing competence [ 14 ]. Moreover, a supportive internship system using motivation strategies as a helpful method improved nursing students’ performance [ 15 ]. In addition, researchers suggested that all the actors involved in nursing students’ internships should facilitate the efficacy of teaching and learning [ 16 ]. Furthermore, another study recommended that stakeholders should use increased educational preparation for the internship stage to evolve healthcare market supply and need [ 17 ].

In order to solve those limitations and promote the program based on the above-mentioned suggestions at the global level, in addition to solving the above points, changes were made in the model A and it was named “nursing student’s internship model B”. For this purpose, director of the Nursing School of Shiraz University of Medical Sciences, their academic teachers, the nursing director of Nemazee hospital, and the director of the provincial nursing office support were considered. More detailed planning was considered to implement and manage the internship model. During the formative evaluation of the model, several meetings between Shiraz Nursing School and the clinical environment were held to identify and resolve deficiencies. Therefore, to improve the evidence-based practice, this study aimed to compare the professional competency and anxiety of nursing students trained based on the two internship models. The following hypotheses were posed:

Nursing student’s internship model B improves the nursing students’ professional competency compared to model A.

Nursing student’s internship model B reduces the nursing students’ anxiety compared to model A.

Study design

This is a comparative study with nonequivalent control group posttest-only quasi-experimental design. In this interventional study with no concurrent controls, a new nursing student’s internship model (B) is proposed. It helps the researchers to select group (B) to be trained using this model and then compare their outcomes to that of a previous nursing student’s internship model group (A). In fact, internship model group (A) was considered as a control group. It should be noted that the students were in two different groups and were selected for each group at two consecutive semesters.

The setting of this study was Nursing and Midwifery School of Shiraz University of Medical Sciences (SUMS). The intervention of nursing student’s internship model group A was carried out routinely from September 2022 to June 2023 and its data were collected in June 2023. The intervention in the nursing student’s internship model group B started from September 2023 and data collection was done in June and July 2024.

Participants

The undergraduate nursing students who were in the seventh and eighth semesters, had passed internship model (A/B) for at least one semester (model A was applied in one semester and model B in the other semester), and were willing to participate were enrolled in this study. Exclusion criteria included a known case of psychiatric disorder confirmed by the doctor according to the student report, incomplete completion of the questionnaires, guest students, and those transferred from another university since the 6th semester because these students might be different from those in the university under study in terms of experience and professional competency. One hundred nursing students participated in this study.

Fifty students were randomly selected among the subjects who passed the internship model (A) Moreover, students who participated in the internship model B were randomly selected to group (B) In order to conduct random sampling for each group, we obtained the list of students in Nursing and Midwifery School of SUMS; based on a random number table, 50 students were selected for each group. For sampling, an individual from outside the team participated.

Sample size

Given that there was no study for comparison on the two groups to evaluate the professional competency and anxiety of nursing students during their internship, the sample size was determined using the study of Liou et al.’s study [ 18 ], which compared the performance competence pre-graduate nursing students and hospital nurses. Based on α = 0.02, β = 0.2, the proportion of subjects that were in the internship model group A = 0.5, proportion of subjects that were in the internship model group B = 0.5, µ 2 - µ 1 of competency = 25.54, SD = 41.35 in Liou et al.’s study and using “Sample Size Calculators for designing clinical research” ( https://sample-size.net/sample-size-means/ ) to compare the mean of a continuous measurement in two samples, the sample size was determined 43 nursing students in each group. Then, considering 15% dropout, it was determined as 50 subjects for each group.

Outcomes and measurements

The outcomes assessed in both groups were professional competency and anxiety. In the demographic form, the gender and age of the nursing students were collected. The professional competency of nursing students was measured using the self-report questionnaire named “The Competency Inventory for Registered Nurses”. It was developed in China by Liu et al. in 2007. Firstly, the inventory had 58 items [ 19 ]. In exploratory factor analysis, three items were deleted and the inventory with 55 items was approved. This inventory consists of the dimensions of clinical care, leadership, interpersonal relation, legal/ethical practice, professional development, teaching/coaching, and critical thinking/research aptitude. Higher scores indicate a higher nursing professional competency. Each item of this inventory was scored using a 5-point Likert scale ranging from score zero (not competent at all) to four (very competent). The total score is 0 to 220 [ 1 ]. A higher score indicates greater competence of the nurse [ 1 , 19 ]. The competence level was placed in three levels of high competence (165–220), medium (110–165) and low (< 110). The reliability of the professional competency inventory was assessed by Liu et al. in 2007, and it was confirmed using Cronbach’s alpha of 0.89 and 0.79–0.86 for the dimensions. The content validity of this checklist was confirmed by Liu et al. and reported as 0.85 [ 1 , 19 ]. Ghasemi et al. assessed the psychometrics of this inventory in the Persian language and the reliability of this checklist using Cronbach’s alpha was 0.90; also, its dimensions were 0.71–0.90 [ 20 ]. As Table  1 shows, in this study, reliability was estimated 0.98 for the professional competency and 0.93–0.95 for its dimensions using Cronbach’s alpha.

The anxiety of nursing students was measured using Spielberger State-Trait Anxiety Inventory (STAI). It was developed by psychologists Charles Spielberger. This inventory has 40 items. Twenty items indicate state anxiety and twenty show trait anxiety. Each item was scored on a four-point Likert scale (not at all = 1, somewhat = 2, moderately so = 3, and very much so = 4). For the total inventory, the minimum score was 40 and maximum score was 160. A lower score means less anxiety and a higher score indicates more anxiety [ 21 ]. The convergent validity and internal consistency of the Persian version of State-Trait Anxiety Inventory were approved [ 22 ]. The normal level of anxiety is shown in Table  2 . In this study, Cronbach’s alpha for total anxiety, state, and trait anxiety was 0.94, 0.91, and 0.89, respectively.

Data collection procedure

Data for this study were collected using the above-mentioned questionnaires. The nursing students of each group were invited to a class in the hospital and clinical setting, the questionnaires were distributed among them, and the students completed them in the presence of the researcher.

Interventions

Internship model a.

As Table  3 shows, in internship model A, at the beginning of semester seven, an introductory meeting was held for the students about the new program. The students in semesters seven and eight were trained in emergency, recovery, operation room, burn, hemodialysis, pediatric departments, neonatal intensive care unit (NICU), intensive care unit (ICU), and Coronary care unit (CCU) by their academic professors. Then, the students passed their internship period after each department/unit. It was in 12 weeks. The nursing students were rotated in critical care, pediatric and medical-surgical units. This period was conducted in the morning shift.

During the internship period, the students were supervised by the ward NUMs or head nurse, and the academic professors randomly followed up and visited the students. The professor talked to the students more about the physical and communication challenges in clinical environment and tried to solve them. In addition, she asked the NUMs and nurses to play a role in the education of students according to their training department and course. The evaluation of students was done by NUMs using evaluation checklists. In addition, if the students had a problem, they informed the head of the department in the faculty.

Internship model B

As Table  3 shows, in the internship model B, at the beginning of semester seven, an introductory meeting was held for the students about the new program. Then, the training classes were held for them, including “how to do drug administration and its nursing care”, “how to handover patients between two shifts”, “how to write the nurse’s note”, “how to perform cardiopulmonary resuscitation”, and “how to work with the DC shock machine”. Moreover, an electronic system was used to register the students’ entry and exit, and the students worked as staff nurses in the department. They were present in a clinical department for a longer period compared to group A. All students were covered by an insurance company for professional services insurance. The following people played an active role in the planning and management of the internship model B:

Manager, vice-chancellors, and the directors of the nursing groups (medical/surgical, critical care, pediatric and community health nursing) in the school of Nursing and Midwifery of SUMS.

Fars provincial nursing office manager and her vice-chancellors.

Nemazee nurse manager and her educational and clinical supervisors.

Vice-chancellors of SUMS.

Firstly, the students were trained in the full-time presence of the academic professors in emergency, burn, hemodialysis and pediatric departments, and operating and recovery rooms. After that, in the internship period, the students spent morning, evening, and night shifts in emergency, pediatric, hemodialysis, medical, and surgical departments. In the eighth academic semester, this program was applied for “maternal and newborn diseases” clinical course, emergency, and “advanced children nursing” departments. During the internship period, the students attended these clinical courses without the direct presence of an academic professor and under the direct supervision of NUMs. As to ICU and CCU, the students spent 12 days with their academic professor and then attended their internship period for 4 weeks. In addition, students spent their morning shifts in the community-based health services department.

During this period, for the first 2 weeks of the shifts, one of the supervising professors, one of the experienced professors, and an expert in diseases and care processes referred to the students’ department and taught the necessary contents based on the patient or patients assigned to the students every day. In the third and fourth weeks, the supervising professors visited the departments 3 times a week and from the 5th week of shifts, two times a week. In these supervisory sessions, in addition to teaching the characteristics of each disease, the patient’s drugs and their specific nursing care, general nursing care such as the principles of dressing, urinary catheterization, tracheostomy suction, prescribing blood products and their complications, and nursing care by the professors, the students were also taught to prescribe high-risk drugs such as KCL, etc.

To consolidate learning, we asked the students to complete assignments related to these trainings and sent them to the professors on social media. Moreover, the supervising professors provided a report on the status and progress of each student on social media and in face-to-face meetings to other professors and those in charge of clinical education that were held monthly in order to facilitate coordination in the education of students. Additionally, the specific patients and their nursing care as “case study” were identified and informed to the head nurse of the clinical education of this course, so that these case studies could be analyzed and presented in the form of clinical and medical grand rounds and workshops. The evaluation of students was done by the academic professors and NUMs using evaluation designed form.

It should be noted that at the end of this study, the contents of training classes were provided for internship model A in the form of MP3 and MP4 files.

Ethical considerations

Research Ethics Committees of Schools of Nursing and Midwifery, Management and Medical Information Science in Shiraz University of Medical Sciences approved this study (IR.SUMS.NUMIMG.REC.1402.027, approval date: 2023-05-28). Participation/non-participation of this study was voluntary. The permission to apply “The Competency Inventory for Registered Nurses” was obtained from Ming Liu by the fourth author of our study. The questionnaires were anonymous. Our study was conducted in accordance with the Declaration of Helsinki. The study purpose, procedure, probable complications and the ways of compensation and the person responsible for these possible complications in this study were explained in a consent form. The consent to participate was obtained from the nursing students. All of the nursing students signed the consent form. We confirmed that this consent was informed. The results of this study were reported to Nursing and Midwifery School of SUMS.

Data analysis

Data analysis of this study was conducted using SPSS version 24. Mean, standard deviation, frequency, and percentage were reported. The Independent Samples t-test was used to compare the means of two independent groups in order to determine whether there is statistical evidence that the associated population means are significantly different. Moreover, multivariate analysis of variance (MANOVA) was used for comparing multivariate sample means. As a multivariate procedure, it is used when there are two or more dependent variables, and is often followed by significance tests involving individual dependent variables separately. In this study, to assess how large the effect of the intervention was on the professional competency and anxiety of nursing students, we measured partial eta squared (η2). According to Cohen 1988, an η2 equal to 0.00-0.01, 0.01–0.06, 0.06–0.14, and 0.14-1 means negligible, small, medium, and large, respectively [ 23 ]. p  < 0.05 was considered as significant.

50% of the nursing students in both groups were female. The mean age of the students was 23.48 (SD = 1.77) and 23.64 (SD = 2.70) in the internship model groups A and B, respectively. No significant difference was observed between the groups regarding gender (χ 2  = 1.00, p  = 0.00) and age (t= -0.34, p  = 0.72) of the students who participated in this study.

As Table  1 ; Fig.  1 show, the mean scores of professional competency were 134.56 (SD = 43.23) and 160.19 (SD = 35.81) for the internship model groups A and B, respectively. Based on these mean scores, nursing students in the internship model groups A and B reported a medium level of professional competency. As displayed in Table  1 , independent sample t-test and MANOVA test showed a significant difference between the groups regarding professional competency and its dimensions ( p  < 0.05). Based on the professional competency η2 that was 0.1, a medium effect size was reported. The highest and lowest η2 among the dimensions of professional competency were related to clinical care and critical thinking/research aptitude, respectively (Table  1 ). Moreover, as Table  1 shows, all the dimensions of professional competency were significantly higher in the internship model group B compared to group A ( p  < 0.05). Moreover, based on the η2 in Table  1 , all professional competency dimensions had medium η2 except for critical thinking/research aptitude that was low.

As Table  4 ; Fig.  1 show, the mean scores of nursing students’ total anxiety were 92.14 (SD = 15.36) and 80.44 (SD = 18.16) in the internship model groups A and B, respectively. Independent sample t-test and MANOVA test showed a significant difference between the groups regarding total anxiety ( p  = 0.001). Based on the anxiety η2 that was 0.11, a medium effect size was indicated (Table  4 ).

Moreover, as shown in Table  4 , the mean scores of state anxiety were 47.43 (SD = 7.27) and 41.32 (SD = 8.62) in the internship model groups A and B, respectively. Based on these mean scores, the nursing students experienced moderate and mild state anxiety in the internship models groups A and B, respectively. Independent sample t-test and MANOVA test indicated a significant difference between the groups regarding the mean scores of state anxiety ( p  < 0.001). Based on the state anxiety η2 that was 0.12, a medium effect size was found.

In addition, as Table  4 shows, the mean scores of trait anxiety were 44.80 (SD = 9.44) and 39.11 (SD = 10.92) in the internship model groups A and B, respectively. Based on these mean scores, both groups of nursing students experienced mild trait anxiety. However, independent sample t-test and MANOVA test showed that the mean score of trait anxiety was significantly lower in the internship model B compared to model A ( p  < 0.05). Based on the trait anxiety η2 that was 0.07, a medium effect size was indicated.

Comparison of the nursing students’ anxiety and professional competency between internship model groups A and B

This study aimed to compare the professional competency and anxiety of nursing students trained based on the two internship models. The nursing students in the internship model group B significantly reported higher mean scores of professional competency and experienced lower mean scores of anxiety compared to the internship model group A.

Our findings revealed that nursing students in the internship model groups A and B reported medium levels of professional competency. A study reported that internship program helped the students achieve clinical competency, and increased academic and professional skills [ 2 ]. Our results indicated that the internship model group B significantly reported higher mean scores of professional competence compared to group A. In a study, it was reported that clinical supervision model in internship nursing students improved the nursing process-based performance [ 9 ]. In the internship model group B, the students had the support of the professor. Their needs were considered by managers, supervisors, professors, etc. The detailed planning of educational and clinical managers reduced the gap between theory and practice and had a positive effect on the internship students. In addition, interactions between professors and students; professors and supervisors, nurses, and patients; students and educational managers; and educational and clinical managers were extensively carried out. The challenges of the students were identified and solved by the team quickly. Possibly, above-mentioned reasons led to improvement of professional competency in the internship group B compared to the internship model A.

Our study showed nursing students in the internship model group B reported higher clinical care and professional development competency compared to the group A. In addition, the group B had higher mean scores of teaching and coaching compared to the group A. Moreover, the highest effect size was related to clinical care competency. A qualitative study reported that the internship program in nursing students improved their clinical skills and “professional self-efficacy”. In addition, these nursing students had professional identity development. They indicated that internship program led to “accepting professional roles” [ 6 ]. In a study on the attitude of nursing students “community-based training and internship”, it was reported that nursing students had a teaching role and provided some of the clients and patients with information regarding lifestyle, mental health, hygiene, etc. [ 3 ]. It seems that in the internship model group B, the full presence of the nursing students in each work shift provided the opportunity to deliver clinical care and educate the patient and colleagues. In addition, because students are still studying, when they encounter new topics, they try to learn them by reading reliable books and Internet sources, asking their peers or supervisors, and providing the nursing staff and the healthcare team with this information. Since there was a lot of emphasis on students’ clinical care in the internship model group B, their supervisors evaluated and taught the skills daily, and the nurses emphasized the students’ education; there was a possibility that this group had better mean scores of clinical care and professional development competency as compared to group A.

This study indicated that interpersonal relations and leadership competency were higher in the internship model group B compared to group A. Researchers believed that in the learning process, interpersonal relationships linked the patients, students, and supervisors to each other [ 24 ]. They suggested that we should respect each other and provide supportive interaction, leading to improvement in learning outcomes [ 24 ]. In clinical setting, interpersonal relationship is crucial for the nurses because it improves the nursing students’ learning and their outcomes [ 25 ]. It seems that better and more frequent interpersonal relations between supervisors, students, and nurses in the internship model group B compared to the group A further improved the nursing students’ competency. In the internship model group B, nursing students worked as staff nurses. They became familiar with facts, documents, etc. Therefore, as they probably knew each other’s strengths and weaknesses and the setting atmosphere and climate, they cooperated better, conducted teamwork, and communicated with other health team members, compared to group A.

Our study showed nursing students in the internship model group B reported higher critical thinking/research aptitude competency compared to group A. However, the smallest difference between the two groups was in this variable. A qualitative study showed the “lack of scientific research training” as a barrier to nursing internship [ 26 ]. A study indicated that critical thinking subscale of performance competence in nursing students’ internship model was in the lowest level [ 18 ]. Therefore, using knowledge and reflecting on it to solve the clinical problems in nursing students needs more attention in both groups.

Our findings showed legal/ethical practice competency had a higher mean score in the internship model group B, compared to group A. Intern nursing students’ moral sensitivity was associated to “ethical decision-making ability” [ 27 ]. It was mentioned that ethical issues would happen in clinical setting among healthcare workers, supervisors, teachers, and patients [ 28 ]. As in the internship model group B, nursing students worked as staff nurses for a long time in a ward/department, it seems that they paid more attention to the security of the patients’ information. Moreover, because they worked as staff nurses, they might have more respect to the patients’ privacy, be more familiar to advocating the rights of the patients, and take more responsibility for their performance compared to group A.

The nursing students experienced moderate and mild state anxiety in the internship models groups A and B, respectively. Moreover, both groups experienced mild trait anxiety. This study indicated that state-trait anxiety was lower in the internship model group B compared to group A. In the same line with the present study, the results of a study in China showed that the anxiety level of nursing students after experiencing the internship program was moderate. Because nursing students are still in the transition phase during internship, their psychological defense mechanisms seem to be incomplete [ 29 ], resulting in experiencing mild to moderate anxiety by them. A study showed that painful experiences during the internship period, feedback and suggestions of trainers, and hard work in the evening and night shifts were the factors that caused anxiety during the internship period [ 11 ]. Of course, researchers believe that moderate anxiety has a protective role and could lead to the improvement of individual ability in response to environmental stimuli [ 11 ]. In group B, holding preparatory workshops for the students before the start of the internship period, close communication between students and academic supervisors, as well as frequent communication and meetings between the hospital nurse managers and educational supervisors with educational and clinical vice-chancellors and academic supervisors probably led to experiencing lower anxiety by nursing students.

This study had some limitations. Since there was no exact control group in this study, it was not possible to compare nursing students who had not experienced these two interventional models and had passed the 7th and 8th semester traditionally, in terms of professional competence and anxiety. Moreover, without a control group, it is impossible to exactly conclude which outcomes were the result of the internship model groups A/B rather than the other variables. Therefore, it is suggested that these interventions should be compared with the control group in other studies and should measure the outcomes before and after the interventions. Given that the study was conducted in only one center (school of Nursing and Midwifery in Shiraz), the generalizability of the findings is not possible. Therefore, it is suggested that the study should be repeated in other schools of nursing in our country and other parts of the world. The fact that the practice was made in different semesters might have an impact on the results; clinical functioning, etc. might be different in that period. There were actually many uncontrollable variables in our study. Therefore, it is suggested to a study in two groups in one semester.

Since the least difference between the two groups was related to the dimension of critical thinking and research aptitude competency, it is suggested that this issue should be given more attention in future internship programs.

This study showed that the nursing students in the internship model group B had a higher mean score of professional competency and lower mean score of anxiety compared to the internship model group A. Given that the internship model group B as a precise and regular program could improve the professional competency of nursing students to a great extent and they experienced mild anxiety during the program, it is suggested that this intervention should be carried out for nursing students and other students who have clinical functions. It is recommended that the internship model group B should be added to the nursing program and curriculum in our country. Since the internship model group B only required detailed planning and we explained it in the intervention section, the model could easily be implemented in different universities.

Data availability

The data of this study would be available by email to Masoume Rambod.

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Acknowledgements

The authors would like to thank the personnel who collaborated in the implication of the intervention and nursing students’ education in clinical settings and Shiraz University of Medical Sciences. The authors would like to thank Razieh Rasekh, Hamideh Falah, Laila Hashemizadeh, and Fatemeh Azadi for preparing and managing the intervention. The authors would like to thank Shiraz University of Medical Sciences, Shiraz, Iran, and Center for Development of Clinical Research of Nemazee Hospital and Dr Nasrin Shokrpour for English language editorial assistance. We appreciated Ming Liu who gave us the permission to apply “The Competency Inventory for Registered Nurses” in this study.

This study was financially supported by Shiraz University of Medical Sciences (Grant Number = 28249).

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Community Based Psychiatric Care Research Center, Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran

Roya Dokoohaki, Masoume Rambod, Nilofar Pasyar, Maryam Shaygan, Majid Najafi Kalyani, Zinat Mohebbi & Azita Jaberi

Department of Nursing, School of Nursing, Larestan University of Medical Sciences, Larestan, Iran

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Contributions

MR, NP, RD, AP participated in conceptualization of this study. RD participated in data collection. MR and AP conducted the management the data analysis. MSH, ZM, AZ, and MN participated in the intervention management. All authors participated in writing and approving the original draft of the manuscript.

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Correspondence to Masoume Rambod .

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Research Ethics Committees of Schools of Nursing and Midwifery, Management and Medical Information Science-Shiraz University of Medical Sciences approved this study (IR.SUMS.NUMIMG.REC.1402.027, approval date: 2023-05-28). Participation/non-participation of this study was voluntary. The permission to apply “The Competency Inventory for Registered Nurses” was obtained from Ming Liu by the fourth author of our study. The questionnaires were anonymous. Our study was conducted in accordance with the Declaration of Helsinki. The study purpose, procedure, probable complications and the ways of compensation, and the person responsible for these possible complications in this study were explained in the consent form. The consent to participate was obtained from the nursing students. All of the nursing students signed the consent form. We confirmed that this consent was informed. The results of this study were reported to Nursing and Midwifery School of SUMS.

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Dokoohaki, R., Rambod, M., Pasyar, N. et al. Comparison of professional competency and anxiety of nursing students trained based on two internship models: a comparative study. BMC Med Educ 24 , 968 (2024). https://doi.org/10.1186/s12909-024-05956-4

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Received : 13 May 2024

Accepted : 26 August 2024

Published : 04 September 2024

DOI : https://doi.org/10.1186/s12909-024-05956-4

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